The promise and challenges of e-cigarettes – the story continues to unfold

There's a bewildering array of products on the market, but we’re starting to understand them better

More than two million people in the UK now use e-cigarettes.

A lot’s changed since we last blogged about them. And over the last year we’ve been monitoring the growing evidence on e-cigarettes, learning more and more about why they’re used and how they will be regulated.

Just this week, they’ve hit the headlines again. On Wednesday, the World Health Organisation recommended a ban on the use of e-cigarettes indoors (something we think is unnecessary).

It’s vital for any organisation like us, which is battling the huge death toll from tobacco, to gather a comprehensive overview of the evidence.

So let’s take another look at what’s happened since we last wrote about e-cigarettes, both in terms of the evidence of their effectiveness, and how they’re being regulated and marketed.

Although the picture still isn’t completely clear, overall we’re cautiously optimistic about their potential. There are still risks to be minimised, but we believe that e-cigarettes have significant potential to help smokers quit by delivering nicotine in a way that seems to be safer than smoking cigarettes.

Are they safer than smoking?

In short – almost certainly yes. E-cigarettes don’t contain tobacco, but instead produce a vapour from nicotine dissolved in one of two chemical compounds – either propylene glycol or glycerine. What else they contain isn’t standardised across the different products.

In contrast, tobacco contains a dangerous cocktail of chemicals which, for half a century, have been known to cause cancer. And lab studies have shown that the levels of these toxins found in e-cigarette vapour are generally far lower than in cigarettes.

But e-cigarettes aren’t as risk-free as the bubblegum or chocolate flavours may suggest. It’s important to remember that they still contain nicotine, which is highly addictive. And because they are relatively new products there still hasn’t been sufficient time to understand what the health impact will be for people who use them long-term.

But, overall, the balance of evidence at the moment suggests that e-cigarettes are much safer than smoking tobacco.

What about the new generation of e-cigarettes?

Many people start vaping with ‘cigalikes’

While there’s been a rapid increase in people using e-cigarettes there are some signs this growth is starting to slow.

There is now a bewildering array of products on the markets, but we’re starting to understand them better.

Many people start vaping with ‘cigalikes’ – products that look like normal tobacco cigarettes and carry a glowing LED tip at the end. But some vapers move onto the refillable ‘tank style’ second generation devices, or the third generation customisable models – which look very different. There is some evidence that users may be able to get a higher dose of nicotine from these high-tech products.

But we need more research on this new generation of products, particularly how they can be best used to help people quit – most of the research to date has focused on people using first generation ‘cigalikes’.

But in the past couple of years, there’s been a big rise in the number of smokers using e-cigarettes as part of their attempt to quit smoking. Swapping regular cigarettes for e-cigarettes offers a less harmful option, which may help some smokers quit smoking for good.

So far there hasn’t been enough evidence to judge their effectiveness as a stand-alone quit aid, or how best they can be used to help smokers quit. But recent results from a study we funded analysed those trying to quit without professional support and found that e-cigarette users were more likely to succeed than those who used no aid or over-the-counter nicotine replacement therapy such as gum and patches. But it’s important to point out that this study still showed that NHS Stop Smoking Services were much more effective in helping people to quit.

So that’s a quick look at the latest evidence of how e-cigarettes used and whether they’re effective. What about how their sale and marketing is regulated?

‘Light touch’ regulation

Unlike quit-aids like nicotine gum and patches, which are regulated as medical products, e-cigarettes are currently regulated as consumer products. This means that they don’t have to provide a list of ingredients, identify the nicotine content, ensure a constant delivery of nicotine, or even be child-proof. So there’s still more that can be done to make sure they are as safe as possible.

This will all change in 2016, when new EU rules will come into force that will improve e-cigarette safety and quality.

E-cigarettes that manufacturers want to continue to sell as consumer products will be regulated under the new Tobacco Products Directive (TPD). This means they’ll come with warnings about the addictiveness of nicotine, restrictions on product design, nicotine content, and manufacturers won’t be allowed to advertise them on TV, radio and in print media.

But if manufacturers want to make claims that their products can help people quit smoking, their e-cigarettes will be regulated as a medicine (in the same way as nicotine gum and patches). They will have to seek a medicines license from the Medicines and Healthcare products Regulatory Agency (MHRA). And if they’re granted a license, they won’t face the same restrictions on strength, design and advertising as those regulated as consumer products, and will still be widely available as over-the-counter medicines, and potentially available on the NHS.

We think these regulations are good news for consumers. We would like to see as many products as possible licensed to maximise the potential for supporting smokers to quit and minimise the potential risks.

And once in place, this should provide the ‘light-touch’ regulations needed to improve the quality and safety of these products, while ensuring that they’re still accessible to smokers and not marketed to non-smokers, including children. Which brings us to our next point.

What about children?

So far, in Great Britain, fewer than one in a hundred children say they’ve used e-cigarettes regularly. And as yet there’s no evidence that e-cigarettes act as a ‘gateway’ into smoking cigarettes. These are encouraging facts.

But as the market for e-cigarettes continues to grow, the situation may change. That’s why we’re pleased to see that the Government plans to ban under-18s from buying e-cigarettes. It will be crucial to track how children respond to these products, and if necessary back further controls on marketing and availability to prevent children using them.

How are they marketed now?

A report we commissioned from Stirling University, looked at e-cigarette marketing and advertising over a year in the UK. The study found a raft of marketing ploys including the use of celebrity endorsements, innovative designs, and sweet-tasting flavours, which might attract non-smokers, including children.

There are also concerns that some e-cigarette advertising may inadvertently ‘normalise’ tobacco smoking making it more acceptable, and perhaps undermining the tobacco control policies that have made a real impact on smoking rates.

The Committees of Advertising Practice recognise these concerns and is planning to introduce new marketing rules for e-cigarettes. We hope these rules will refine marketing regulations, to ensure e-cigarettes are targeted at those who can benefit – namely smokers and users of nicotine-containing products – and not to non-smokers.

Do they change what people think about smoking?

In recent years, smoking has become less socially acceptable, but as is clear from the ‘cigalike’ products, vaping can mimic smoking, which may start to make smoking acceptable again. Is there any evidence for this? Not yet, but like with other areas of e-cigarette research there just simply hasn’t been enough time to be sure either way.

In reaction to these concerns, the Welsh Government is exploring a ban on vaping in all enclosed public spaces, fearing that it may make smoking acceptable again. We don’t believe that there is currently sufficient evidence to justify this. But through our continued support of research, these answers will become clearer, allowing governments to make evidence-based decisions. In the short term, expert guidance is available to businesses to help them make informed decisions on whether to permit e-cigarette use within their premises.

What about the tobacco industry?

E-cigarettes aren’t just big news, they’re big business. And the tobacco industry’s growing interest in this business is a serious concern.

In the last year the tobacco industry has started launching their own products and buying more established e-cigarette companies. It’s not clear why they are interested in e-cigarettes – is it as an insurance policy from declining tobacco sales? Or another ploy to improve their reputation? Either way their involvement raises concerns due to serious conflicts of interest.

The World Health Organisation’s Framework Convention on Tobacco Control (FCTC) is a global public health treaty, signed by 178 nations, aimed at reducing the harm from smoking. All members are required to protect their health policy from the influence of the tobacco industry. As we’ve highlighted before, the tobacco industry isn’t to be trusted when it comes to trying to influence policy.

So we’ll be keeping a close eye on its involvement in e-cigarettes to ensure they can’t use their investment to influence public health policy again.

Maximising the potential

While it’s clear that e-cigarettes have enormous potential to cut smoking rates, it’s vital that all other potential consequences are taken into account. By building and acting on the evolving evidence base around e-cigarettes we believe their full potential can be realised, and the risks minimised.

The debate around e-cigarettes isn’t likely to be resolved any time soon, and we’ll likely continue to see headlines about their risks and benefits for some time to come.

For our part, we will continue to invest in e-cigarette research, presenting a clear assessment of the evidence for those who need it.

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I have been quit over 3 years thanks to the e cig, i made my own e juice which ti begin with consisted of 60% glycerol, 20% water 10% water and 10% food flavouring, all of these contents bar the nicotine are found in the baking isle of your local supermarket and are safe for consumption (also used for years in smoke machines at parties), i eventually dropped the nicotine and then the e cig and have never looked back

Anything that helps people quit smoking is good. Even if they continue to use E-cigs.
About it normalising smoking: Well if normal cigarettes were completely banned, and no longer manufactured, then normalisation wouldn’t matter would it? I suppose it would take time to reach that but why not start now? The worst problem is that it would have to a world wide effort. Why not though? The health issues are world wide.
It could happen.

I think there is a case for banning e cigarettes indoors. They mimic smoking, normalising the practice if inside. They are adictive and I don’t feel that businesses and workplaces should condone ongoing addiction, we don’t drink or shoot up at our desks after all. As a tool for stopping I can see they have value but that doesn’t have to take place inside, and often they are NOT about quitting, they are recreational. I would not like children seeing adults engaged in addictive behaviour, or copying the smoking action.

e-cigarettes are just another way to keep smokers in this vicious circle of nicotine addiction.

The best way to stop smoking is by understanding why you smoke, the process behind this addiction and how to make it psychologically easier to stop, to transform this painful experience into something really positive.

I am very sad to see that the major organisations in our country always end up backing the unhealthy solutions provided by big pharmaceutical companies, while other solutions such as Allen Carr’s clinics, which have a whooping 80% success rate don’t get any coverage. Allen Carr was recommended by my GP in 2007 and I wish I had known about them 25 years ago when nicotine had not destroyed my health yet.

I have concerns over the second hand chemicals that have been exhaled. I am not medical qualified but it’s not unreasonable to presume that not all the products chemicals are absorbed into the user. I personally feel I should have the right to have a chemical fee air around me

Thanks for this great article, it’s nice to see that the UK is uninfluenced by big tobacco organisations and health bodies can freely write unbiased material.

I think that we can now see that short term effects are really nothing of concern and are even beginning to see that long term effects are at the very least indicating that it will be far less damaging than the combustion of herbal tobacco.

They aren’t absolutely perfect, but if they turn out to be as good as the appear it will mean great things for the health and well being of millions.

There are issues regarding the chemicals used in the flavoring process and whilst I am for the use of e cigs (I personally prefer the term vaping as I want to move away from the association), there should be tighter regulations on the production, I wouldnt go as far as medical testing as the costs could ruin the industry at this early stage. Similar test requirements and production laws to that of food products would be adequate in my opinion.

Please do more research into second and third generation devices, some evidence is actually beginning to show less nicotine consumption as the user is forced to drop the nicotine level to adjust for increased vapor production. Some people are reporting that they are testing negative or below the threshold for nicotine or cotinine levels in blood for insurance purposes. I am sure that this is at the cost of more propylene glycol/vegetable glycerin consumption, but again there doesn’t seem to be too many problems associated with this, at least far less than smoking tobacco.

E cigs have turned our lives around in so many great ways. Both myself and my fiance (previously heavy smokers) now feel healthier and happier for the swap to vaping. We started on a high nicotine content, now we are on the lowest nicotine content 1 year later. We enjoy the hand to mouth action required to use a vaping device, s smokers this seems to be a comforting and relaxing thing to do. Our toddler is happy too as we have a healthy, smoke free home. Interested in what the future investigations in these products conclude, as I agree we don’t know enough about them yet, but I am certain they are a much better alternative to smoking.

I actually went cold turkey nearly 6 yrs ago after smoking all of my adult life (at least 20 a day on bad days) .I’m now 51! and am still smoke free ! ☺ patches etc (including e-fags) are a waste of time and money. All you need is an iron will and want to give up, you will then succeed. I actually put old cigarette butts in a jar and had a sniff if I had a desire to smoke…and guess what..It works..desire melted away! when you actually analyse what smoking actually is..It’s a very sad and totally anti-social activity. just give it up to save your life and live your life with those that love you

I have seen no mention of the effect of e-cigarettes on people near the uses. My husband says he feels his chest is affected by the vapour. We would like to find out more about any side effects to non-smokers in a room with users.

I have just completed my first year of being cigarette free! Not one has passed my lips, much to my own amazement ….I cannot believe how conscious I am now of the smell, outside and on peoples clothes it really is foul! I never realised how bad I must of smelt all the time. I know that without E-cigs I would not have given up with willpower alone, gum or patches. I would like more information as to what these e-cigs contain but, until I find out that they are harmful I will continue as I am thankful that they have made me quit the fags!!! My only issue is that I have gained a stone in weight that I cannot shift……Heyho can’t have everything I guess!

I do not think e-cigarettes should be taken as the way forward from smoking tobacco. In my experience I have still reacted to the vapour as I do with cigarette smoke, and with chronic bronchitis, this new fad exacerbates my problems, in all encounters I have had trouble breathing and coughing spasms, and on one occasion one person openly laughed at my discomfort! Many of my friends simply do not like the smell from them, as it gives them migraines, so I am not alone. I am quite disappointed that you feel the need to openly say that they are safer than smoking, as research has shown this not to be the case. It will be many years, as was the case with cigarettes, to discover the true facts. Second hand vaping effects and indeed third hand vaping effects have been proven only recently.

Good to find such a balanced analysis. Anecdotally I know of people who have tried everything else in order to quit, to no avail, but feel that e-cigs are the answer. To ban them in public spaces would ostracise vapers as social lepers and may well make them start smoking tobacco again as they would be once more outside with the smokers. There is no evidence vaping is harmful. Certainly no evidence that it harms third parties, therefore no justification to ban it.

I have been using nrt for 10 years on and off unfortunately more off than on but doing well at moment,one of the biggest incentives when I’m using nrt is the money which is y I believe the tobaco industries shud be forced to contribute untill they have exhausted all there funds and can no longer produce cigaretts 2 birds 1 stone,when they got me hooked on nicotine I was very young long time b4 regulation and I fail to see why I or the nhs which has helped so much by the way,thanks,should be responsible for the bill for my rehabilitation which I fear I may never win,I am currently attempting to swap vamping for nhs inhaler as on ain’t endive fitness programme and hav noticed a little tension in my chest when I use vaper,the inhalers are very good although I have a tendency to overdose on them which is not pleasent

I stopped smoking cigarettes 6 year ago after contracting Breast Cancer. I enjoyed smoking and if Im honest I didnt want to stop, I went onto nicotine gum replacement and was on this for 5 years! I decided to try E cigs and I am happier to be on them than the gum. Im aware these nicotine replacements arent supposed to be a permanent fix but I have accepted Im addicted to nicotine and aslong as I can have my e cig I wouldnt thank you for a cigarette now. Im pleased Cancer research is looking into the safety of these e cigs, If Im honest I dont know how Id feel if they turned out to be really bad for you, but at this time Im happy to continue using them. Ive been using my E cig for a year…and I feel great!

I was a 20 a day smoker for 17 years and had many failed attempts to give up using patches and champex. March the 14th 2014 I bought a vaper ecig and from that day on I haven’t touched a cigarette and I’ve no desire or craving to. I’m saving around £250 a month and feel so much better health wise. I’m now at a stage where I can take or leave my ecig if I go out and realise I’ve left it at home I don’t get that panic feel I would have when I was a smoker. I personally urge anyone thinking of giving up smoking to try one, they cost very little and can save not only your cash but your life.

I stopped smoking on the 9th October 2012 after being told by three soccer I had a year maybe 2 of I carried on smoking, after a12 week course on champex I was still finding it hard as I enjoyed the smoke !!!, so I started using ecigs with no nicotine and I’ve been using these since then, I’ve had check ups xrays and so on, and my chest is clear I can breath better, so ecigs are the way to go.

I have been using an e-cigarette for 3 months and I tried a menthol cigarette that I used to smoke and enjoy and it made me feel so sick. The taste was horrible. I couldnt believe I was actually put off by it. This is all well and good but I do worry about how I will now quit my e-cigarette :(

Firstly I am so pleased that CR-UK is now taking an evidence based view, rather than the original emotional bias:we are conditioned to think Nicotine is deadly when the truth is burning tobacco products, especially those adulterated by tobacco companies, is deadly.

I applaud you.

However, I disagree wholehartedly that the European Tobacco Products Directive will “improve safety and quality”… The truth is that this will stifle the market, remove the essential variety of flavours, captivate users to particular brands, render almost every product on the market unsaleable and, through cost of entry, obscenely give the entire industry to tobacco and pharmaceutical companies (which will in turn generate the twin evils of a wholly unregulated black market and force users to accept whatever additives the above industries deem to put in – tobacco companies especially have a bit of a reputation.

Regarding “There is some evidence that users may be able to get a higher dose of nicotine from these high-tech products” there are two flaws…
Firstly these are low or zero tech devices (I don’t use any electronics and know exactly what I’m vaping, down to analysis of flavourings and have absolute control over my product.
Secondly, users naturally limit the amount of nicotine they consume – it’s called self titrating (so although they may be able to, they won’t)…. Relating to this, if the user (at the hobbyist range with RDA’s and RBA’s) is using a more efficient atomiser that will release more nicotine and increase flavour at a given heating element wattage, they will reduce the concentration of nicotine in the liquid. All of which will be moot in 2016.

I suggest that these devices are unlikely to re-normalise actual smoking. The reason for this is simple , to non smokers, which includes most e-cig users, smoking makes you smell to high heaven , not attractive.

“nicotine dissolved in one of two chemical compounds – either propylene glycol or glycerine. What else they contain isn’t standardised”
propylene glycol AND/OR glycerine Most use a combination and often users can specify the ratio of these two they prefer.
0-3% nicotine, 0-12% water (glycerin is too thick without added water) 0-25% natural and artificial flavors. So we know whats in them as much as we know whats in any processed food on the shelf.
These are food flavors used for Soda, Candy, breakfast cereal, baking etc. Usually their exact composition is a trade-secret of the company that makes them – but they are regulated as food additives and can’t be poisons or drugs. However a few flavor chemicals have been found that are bad to inhale despite being fine to swallow.
The e-juice company should be responsible to test for those chemicals but they often take the word of the flavor companies that particular flavor chemicals are not included.

A far more pragmatic position than 12 months ago ,but still a number of changes are still required. Whilst you didn’t actually state it I got the distinct impression that you were not convinced with the need for a multitude of flavours(consumers choice) – these are of vital importance in maintaining the success of e-cig effectiveness in converting from lit tobacco . The TPD in no way could be described as “light touch” regarding its draconian measures based on totally flawed premise of harmful or lethal dose of nicotine (actually 20-30x higher than levels used in the regulation making) . The TPD has many contentious issues that were hastily pushed through in the trialogue process in December 2013 the full implications of which will have unintended consequences – advertising and free discussion of the products is required to further spread the appeal to smokers who wish to convert .

So overall a welcome change in tone from CR-UK but still you are missing the point in key areas -please consider some of the points made

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